Hurricane Otis slammed into Acapulco, Mexico, in the early morning hours of October 25 with sustained winds of 165 miles per hour. The storm wrought catastrophic damage throughout the coastal city, known for its resorts, and at least 45 people were killed, and dozens remain missing. Local officials have said that 80% of hotels were seriously damaged.

Dr. Giorgio Franyuti, the founder and head of Medical Impact, a Mexico-based medical aid nonprofit that organizes monthly missions into underserved communities domestically and responds to disasters both at home and internationally, said the scale of devastation was well beyond anything he had seen in his career, which has spanned war zones, earthquakes, and volcano eruptions.

“This Category 5 storm was enormous… We didn’t even know where to start,” he said.

Determining that Acapulco would receive the most resources from the government and aid groups, Franyuti and his staff physicians organized a mission inland to the mountainous rural communities of Guerrero state and traveled to five different municipalities.

Before reaching the last one on their mission, Ejido Viejo, the Mexican military had to clear a path since existing roads were completely destroyed. The town had been cut off for over a week.

“It was horrendous. The houses were still drowning in mud. The cars were drowning in mud. Bodies were yet to be found,” he said. “We discovered a massacre.”

He plans to return next week with his team to continue treating survivors. Franyuti said that in his experience, which reflects the latest medical literature, the time after a natural disaster is oftentimes more deadly than the disaster itself.

“The secondary disaster is bigger than the first one. The earthquake or hurricane doesn’t kill as many people as the water shortages, for example, will. The cuts in basic services will cause major death among those affected by the hurricane,” he said.

The lack of refrigeration, combined with limited access to quality food, potable water, and gas for cooking food and boiling water, represents an extremely dangerous combination of challenges facing communities in rural Guerrero, which were vulnerable even before the storm, according to Franyuti, who said lack of clean water is the top priority.

He said he is concerned about the spread of a range of infectious diseases. Franyuti said diarrhea could kill more people than the hurricane due to the lack of oral rehydration salts and drinkable water in the area. Mosquitos, which could flourish in standing water near homes, also present a problem as some will likely vectorize diseases such as chikungunya, dengue fever, and zika. He predicts that the scarce local services will be oversaturated by these infections.

As is the case following most natural disasters, Medical Impact is working to address the shortages and barriers vulnerable communities have towards accessing chronic disease medication, particularly therapies that require being kept at cool temperatures, such as insulin. In Mexico, complications from diabetes are the second-leading cause of death.

Despite the level of need, Franyuti said the level of response has not been in line with the situation on the ground.

“I think what is worrisome compared to other disasters in the past is that while the media has given this wide attention, stakeholders have not,” he said.

Medical Impact is preparing for at least four more missions to address this crisis, each lasting for one week. Franyuti said his team has been the only one responding to these areas.

Direct Relief has been responding to Acapulco, equipping organizations with requested medical aid, including Medical Impact. The organization received a $25,000 emergency operating grant to deploy doctors to Acapulco to provide medical care in the area. Field medic packs and an emergency health kit, which contains medical essentials commonly requested after disasters, were also provided for medical providers from Direct Relief.